Needle Decompression — Tension Pneumothorax
Tension pneumothorax occurs when air accumulates in the pleural space under pressure, collapsing the ipsilateral lung and shifting the mediastinum. It's immediately life-threatening. Needle decompression is the definitive prehospital treatment.
Diagnosis
- Absent or severely diminished breath sounds on the affected side
- Hypotension and shock
- Tracheal deviation toward the opposite side (late, unreliable finding)
- Distended neck veins (JVD)
- History: penetrating chest trauma, rib fractures, barotrauma from mechanical ventilation
Tracheal deviation is a late, often absent finding. If you have a suspected tension pneumo with hypotension and absent breath sounds in a trauma patient — decompress now. The diagnosis is clinical. A unnecessary needle decompression in a simple pneumo causes minor morbidity; a missed tension pneumo causes death.
Procedure — Two Accepted Landmarks
- Classic: 2nd ICS, midclavicular line (MCL) — Upper border of the 3rd rib (neurovascular bundle runs inferior to each rib). Insert 14–16g angiocath perpendicular to chest wall. Listen for rush of air.
- Alternative: 4th–5th ICS, anterior axillary line (AAL) — Higher success rate in obese patients and heavy chest walls. Less risk of hitting lung. Some protocols now prefer this site.
- After insertion: tape catheter in place, remove needle, leave hub open
- Reassess — if improvement, proceed. If no improvement, consider bilateral tension or missed placement.
- Finger thoracostomy if needle fails (surgical opening — hospital skill in most systems)
Tranexamic Acid (TXA)
TXA is an antifibrinolytic — it prevents clots from breaking down once formed. In massive hemorrhage, the body's clotting system becomes overwhelmed, clots dissolve faster than they form, and bleeding becomes uncontrollable. TXA stops this cycle.
- Dose: 1 g IV over 10 minutes, followed by 1 g IV over 8 hours (second dose in-hospital)
- Give within 3 hours of injury — benefit decreases rapidly after 3 hours, and evidence suggests harm if given after 3 hours
- Indications: significant hemorrhage with suspected coagulopathy, penetrating trauma, MVC with significant mechanism
- Contraindications: >3 hours post-injury, no evidence of significant bleeding, history of clotting disorder
Permissive Hypotension (Damage Control Resuscitation)
In hemorrhagic shock from penetrating trauma or surgical bleeding, aggressive IV fluid replacement dilutes clotting factors and disrupts forming clots — worsening bleeding. The strategy of permissive hypotension accepts a lower BP to preserve clot integrity until surgical hemorrhage control.
- Target: systolic BP 80–90 mmHg in penetrating trauma without TBI
- Target: systolic BP 90–100 mmHg if traumatic brain injury is present (brain needs perfusion pressure)
- Give fluid in small boluses (250–500 mL) and reassess rather than running wide open
- Stop fluids when BP reaches target — more is not better
- Blood products (packed RBCs, FFP, platelets) are superior to crystalloids when available
Hypothermia + Acidosis + Coagulopathy form a lethal cycle in severe trauma — each worsens the others. Prevent hypothermia (cover, warm fluids), correct acidosis (oxygenation, ventilation), and preserve coagulation (permissive hypotension, TXA, avoid crystalloid overload). This is why damage control resuscitation exists.
Flail Chest
Three or more consecutive ribs fractured in two or more places creates a free-floating segment. This segment moves paradoxically — inward during inspiration, outward during expiration — impairing ventilation. The underlying pulmonary contusion is the bigger problem.
- Signs: paradoxical chest wall movement, severe pain, respiratory distress, decreased breath sounds
- Treatment: O₂, analgesia (fentanyl), positive pressure ventilation (BVM or intubation) for severe respiratory failure
- Do NOT apply sandbags or tape the flail segment — this was old dogma, now discouraged
Hemothorax
Blood accumulating in the pleural space. Can hold 2–4 liters before affecting ventilation. Signs: decreased breath sounds (dull to percussion), signs of hemorrhagic shock. Treatment: thoracostomy/chest tube (hospital). Prehospital: treat shock, rapid transport.